Like HIV, gender-based violence (GBV) has implications for almost every aspect of health and development. This guide serves as a tool for program managers to not only begin to address GBV within their programs, but also to plan for greater integration and coordination within country teams when designing workplans and budgets. The guide is divided into several smaller parts. We strongly recommend reviewing all parts of the guide in order to take advantage of the full range of opportunities to address GBV and to achieve the goal of greater linkages between HIV prevention, treatment, care, and support. See Introduction, Guiding Principles, General Guidelines and Summary of Resources on the right. www.aidstar-one.com/focus_areas/gender/resources/pepfar_gbv_program_guide

1. |
GENDER-BASED VIOLENCE AND
HIV
A PROGRAM GUIDE FOR INTEGRATING GENDER-
BASED VIOLENCE PREVENTION AND RESPONSE IN
PEPFAR PROGRAMS
______________________________________________________________________________________
OCTOBER 2011
This publication was made possible through the support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
through the U.S. Agency for International Development under contract number GHH-I-00-07-00059-00, AIDS Support and
Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.

3. GENDER-BASED VIOLENCE
AND HIV
A PROGRAM GUIDE FOR INTEGRATING GENDER-
BASED VIOLENCE PREVENTION AND RESPONSE IN
PEPFAR PROGRAMS
The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for
International Development or the United States Government.

4. AIDS Support and Technical Assistance Resources Project
AIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) is funded by the
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International
Development (USAID) under contract no. GHH-I-00–07–00059–00, funded January 31, 2008. AIDSTAR-
One is implemented by John Snow, Inc., in collaboration with Broad Reach Healthcare, Encompass, LLC,
International Center for Research on Women, MAP International, Mothers 2 Mothers, Social and Scientific
Systems, Inc., University of Alabama at Birmingham, the White Ribbon Alliance for Safe Motherhood, and
World Education. The project provides technical assistance services to the Office of HIV/AIDS and USG
country teams in knowledge management, technical leadership, program sustainability, strategic planning, and
program implementation support.
Recommended Citation
Khan, Alia. 2011. Gender-based Violence and HIV: A Program Guide for Integrating Gender-based Violence Prevention
and Response in PEPFAR Programs. Arlington, VA: USAID’s AIDS Support and Technical Assistance
Resources, AIDSTAR-One, Task Order 1.
Acknowledgments
Many thanks to the members of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Gender
Technical Working Group for its leadership in conceptualizing and overseeing the development of this guide.
Thanks also to the following individuals for their participation in the Technical Advisory Group consultations
to develop this guide and for their thoughtful review and contributions: Avni Amin (World Health
Organization [WHO]), Ginna Anderson (International Community of Women Living with HIV), Doris
Bartel (CARE), Claudia Briones (UN Women), Manuel Contreras (International Center for Research on
Women [ICRW]), Mary Ellen Duke (U.S. Agency for International Development [USAID]), Mary Ellsberg
(ICRW), Diane Gardsbane (EnCompass LLC), Jill Gay (independent consultant), Jessie Gleckel (U.S. Health
and Human Services Centers for Disease Control and Prevention [CDC]), Alessandra C. Guedes (Pan
American Health Organization/WHO), Andrea Halverson (USAID), Daniela Ligiero (Office of the U.S.
Global AIDS Coordinator), Ronnie Lovich (Save the Children), Lyn Messner (EnCompass LLC), Sasha Mital
(CDC), Claudia Garcia Moreno (WHO), Kellie Moss (Kaiser Family Foundation), Patricia Poppe (Johns
Hopkins University Center for Communication Programs), Diana Prieto (USAID), Samira Sami (CDC), Kai
Spratt (USAID), and Pamela Wyville-Staples (USAID). Thanks to the following PEPFAR Technical Working
Groups for reviewing relevant sections of the guide: HIV Testing and Counseling, Prevention of Mother-to-
Child Transmission, Orphans and Vulnerable Children, Most at-Risk Populations, and Adult Treatment; and
to the AIDSTAR-One Gender Team for their support in the development and publication of this guide.
AIDSTAR-One
John Snow, Inc.
1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
E-mail: info@aidstar-one.com
Internet: aidstar-one.com

5. CONTENTS
Acronyms............................................................................................................................................................................. v
Introduction ........................................................................................................................................................................ 7
Why Link Gender-based Violence and HIV Programs? ....................................................................................... 7
The Case for Integrating Gender-based Violence Services ................................................................................ 8
About this Guide .......................................................................................................................................................... 9
Limitations of the Guide ........................................................................................................................................... 10
How to Use the Guide .............................................................................................................................................. 11
Methodology ................................................................................................................................................................ 12
Guiding Principles for Working with Survivors of Gender-based Violence ...................................................... 13
Guidelines for Gender-based Violence Programming ............................................................................................ 19
Prevention ......................................................................................................................................................................... 29
HIV Testing and Counseling .......................................................................................................................................... 33
Prevention of Mother-to-Child Transmission........................................................................................................... 39
Adult Treatment .............................................................................................................................................................. 45
Care and Support ............................................................................................................................................................ 51
Orphans and Vulnerable Children ............................................................................................................................... 55
References ......................................................................................................................................................................... 59
Recommended Resources ............................................................................................................................................. 61
iii

6. iv

7. ACRONYMS
ACORD Agency for Cooperation and Research in Development
ART antiretroviral therapy
CDC Centers for Disease Control and Prevention
CHTC couples HIV testing and counseling
FHI Family Health International (now known as FHI 360)
GBV gender-based violence
GNP+ Global Network for People Living with HIV
HTC HIV testing and counseling
IASC Inter-Agency Standing Committee
ICRW International Center for Research on Women
IGWG Inter-Agency Gender Working Group
IHAA International HIV/AIDS Alliance
IPPF International Planned Parenthood Federation
IRC International Rescue Committee
M&E monitoring and evaluation
MARP most-at-risk population
MSM men who have sex with men
OHA Office of HIV/AIDS
OVC orphans and vulnerable children
PAHO Pan American Health Organization
PEPFAR U.S. President’s Emergency Plan for AIDS Relief
PLHIV people living with HIV
PMTCT prevention of mother-to-child transmission
RHRC Reproductive Health for Refugees Consortium
STI sexually transmitted infection
UNAIDS Joint U.N. Programme on HIV/AIDS
UNDAW U.N. Division for the Advancement of Women
UNFPA U.N. Population Fund
UNHCR U.N. Refugee Agency
v

8. UNICEF U.N. Children’s Fund
UN Women U.N. Entity for Gender Equality and the Empowerment of Women
USAID U.S. Agency for International Development
WHO World Health Organization
vi

9. INTRODUCTION
While there is mounting evidence that gender-based violence (GBV) is both a cause and
consequence of HIV infection, programs and services designed to address these pandemics are
largely fragmented. This guide offers a starting point for U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) program managers to integrate a basic response to GBV within existing HIV
programs and to establish linkages with other efforts that are addressing GBV.
WHY LINK GENDER- Defining Gender-Based Violence
In the broadest terms, “gender-based
BASED VIOLENCE AND violence” is violence that is directed at an
HIV PROGRAMS? individual based on his or her biological sex,
gender identity, or his or her perceived
Violence or the fear of violence can pose adherence to socially defined norms of
formidable barriers to HIV prevention, care, masculinity and femininity. It includes physical,
and treatment, limiting individuals’ ability to sexual, and psychological abuse; threats;
learn their status and adopt and maintain coercion; arbitrary deprivation of liberty; and
protective measures ranging from negotiating economic deprivation, whether occurring in
safer sex to getting and staying on treatment to public or private life.
remaining in school (Gardsbane 2010; World
Health Organization [WHO] and the Joint U.N. GBV takes on many forms and can occur
Programme on HIV/AIDS [UNAIDS] 2010). throughout the lifecycle, from the prenatal
Similarly, violence can impede access to basic phase through childhood and adolescence, the
health information and services, including HIV reproductive years, and old age (Moreno
treatment, care, and support. Conversely, a 2005). Types of GBV include female
positive test result can lead to stigma, infanticide; harmful traditional practices such
discrimination, isolation, and violence in the as early and forced marriage, “honor” killings,
home and community, magnifying the and female genital cutting; child sexual abuse
vulnerabilities that women, girls, orphans and and slavery; trafficking in persons; sexual
vulnerable children (OVC), and other at-risk coercion and abuse; neglect; domestic violence;
populations already face in pursuing healthy, and elder abuse.
satisfying, and productive lives (Hale and Women and girls are the most at risk and most
Vazquez 2011). Research studies from India, affected by GBV. Consequently, the terms
Kenya, Rwanda, South Africa, Tanzania, the “violence against women” and “gender-based
United Kingdom, the United States, and violence” are often used interchangeably.
Vietnam demonstrate that women who are However, boys and men can also experience
HIV-positive are more at risk of violence than GBV, as can sexual and gender minorities,
women who are HIV-negative, and that such as men who have sex with men and
violence is a major contributing factor to HIV transgender persons. Regardless of the target,
infection (Program on International Health and GBV is rooted in structural inequalities
Human Rights and Harvard School of Public between men and women and is characterized
Health 2009). by the use and abuse of physical, emotional, or
financial power and control.
7

10. Like HIV, GBV has implications for almost every aspect of health and development from access to
and use of health services to educational attainment, economic empowerment, and full enjoyment of
human rights. The similarities between these two mutually reinforcing pandemics do not end there.
Women, girls, and other at-risk populations’ distinct vulnerability to HIV and GBV are rooted in
structural inequalities—i.e., unequal power relationships based on biological sex, gender identity, and
sexual orientation—that are codified via cultural beliefs and societal norms and are reinforced in
political and economic systems.
Linking GBV and HIV efforts is both a necessary and a potentially powerful strategy for eliminating
the structural drivers of each and achieving lasting results in the fight against HIV. Both require a
comprehensive response: one that simultaneously addresses the biomedical, behavioral, and social
risk factors and implications for affected populations. Both require well-coordinated, multi-sectoral
efforts that address the multiple dimensions in which violence and HIV infection can affect peoples’
lives, including their health, education, social interactions, economic opportunities, safety, legal
protections, and human rights. And both must be addressed on a continuous basis throughout the
lifecycle to ensure lasting results.
THE CASE FOR INTEGRATING GENDER-BASED
VIOLENCE SERVICES
Integrated health services provided within the context of well-coordinated referral networks and
social services is a recognized strategy for meeting the unique health needs of women and children
(Ferdinand 2009; Global Health Initiative n.d.; Women Won’t Wait 2010). While health services and
programs may be fragmented, individual health and social needs are comprehensive, including
multiple types of care (e.g., primary care, family planning and sexual and reproductive health,
antenatal and maternal health care, child health) and social services (e.g., education, livelihood
programs, legal assistance). Strengthening linkages and integration between and among services can
increase access, which is a fundamental priority for individuals who already face barriers due to
poverty, low social status, lack of education, stigma, discrimination, and GBV (Keesbury and Askew
2010; Morel-Seytoux et al. 2010).
Emerging evidence regarding integrated programs has found that access to comprehensive services,
whether through one-stop centers, co-location of services, or functional referral systems, among
other strategies, can produce better outcomes for GBV survivors (Keesbury and Askew 2010).
Training programs for different cadres of health care workers, police, and community leaders have
been shown to increase individuals’ comfort level with respect to addressing GBV, paving the way
for victim-centered services, community-based violence prevention efforts, increased utilization of
HIV testing and counseling (HTC) services, and better adherence to antiretroviral therapy (ART): all
essential elements for achieving lasting success in the fight against HIV (Keesbury et al. 2011).
Research studies and program evaluations also point to challenges to integration, largely related to
the pressure on already overburdened health systems (Keesbury et al. 2011). Health care worker
shortages, burnout, poor infrastructure, lack of emergency equipment and supplies, long wait times,
and inadequate geographic coverage must be addressed not only within the context of HIV
prevention, care, and support, but in broader attempts to integrate services (Keesbury and Askew
2010; Keesbury et al. 2011). In addition, discriminatory norms, laws, and policies, for example,
relating to HIV status, property rights, and high-risk behaviors, both statutory and customary, create
an enabling environment for violence and pose barriers to receiving comprehensive, compassionate
care that fully respects individuals’ dignity and rights (Spratt 2010). However, though challenges
8

11. exist, this should not be construed as an argument against integration. Rather, they identify clear
priorities for ensuring that health and development efforts are gender sensitive, promote universal
access to needed services, and respect and promote human rights.
ABOUT THIS GUIDE
The authorizing legislation for PEPFAR specifies that PEPFAR will support five high priority areas,
including reducing GBV and coercion, challenging negative male norms, and expanding women’s
legal rights and protections (Lantos and Hyde 2008). This legislation includes both programmatic
and budgetary reporting requirements on gender-sensitive activities as well as inclusion of gender
equality in partnership frameworks. Accordingly, PEPFAR’s five-year strategy aims to link HIV
services to broader delivery mechanisms that improve health outcomes for women and children,
including by expanding PEPFAR’s commitment to cross-cutting integration of gender equality in its
programs and policies, with a renewed focus on addressing and reducing GBV (Office of the U.S.
Global AIDS Coordinator 2009). Likewise, a focus on women, girls, and gender equality, including
the prevention of and response to GBV, is a key priority of the U.S. Global Health Initiative (Global
Health Initiative n.d.).
This guide is designed to help PEPFAR program managers address and respond to GBV within
HIV prevention, care, and treatment programs. It serves as a starting point for HIV programs and
services to contribute to a comprehensive response to GBV including through direct services for
GBV survivors, community mobilization to address the root causes of violence, capacity building
for service providers, and policy change and leadership to create an enabling environment for
preventing, addressing, and ultimately ending GBV. In addition to mobilizing a comprehensive
response to GBV, the issues, strategies, and actions presented are intended to reflect consensus-
based recommendations from public health experts, women’s groups, reference agencies such as
WHO and the Centers for Disease Control and Prevention (CDC), academic researchers,
development partners, and others. These include using an evidence- and rights-based, gender-
sensitive approach; fostering strong, functional linkages and integration within and between services
and programs; mobilizing communities to address harmful gender norms that contribute to violence;
coordinating across sectors; and monitoring and evaluating outcomes and impact to provide holistic
services that address the legal, health, education, economic, and other needs of survivors, their
families, and communities (see Figure 1).
While there is increasing political momentum to end GBV, including through greater integration and
linkages with HIV programs, this guide was written with the understanding that HIV programs may
already be operating on limited budgets and within resource-constrained settings. This is not a
rationale for omitting or minimizing a response to GBV, but rather is an acknowledgment of the
fact that program planners and implementers will continue to have to do more within existing
budgets and rely on greater integration, coordination, and efficiencies within and across
development efforts. Therefore, this guide is not intended to be prescriptive, and it does not assume
that all programs can adopt all strategies and tactics presented here.
Instead, it aims to assist HIV program managers and implementers to first see and understand the
relationship between HIV and GBV. Next, it identifies opportunities for establishing linkages, for
example, by conducting sensitivity trainings on the relationship between GBV and HIV or
establishing relationships with women’s groups that are already working on GBV. Finally, it includes
information on integrating basic GBV response and prevention services into existing HIV programs,
9

12. Figure 1. Comprehensive, multi-sectoral response to GBV
for example, training HTC and adherence counselors to offer GBV screening, counseling, and
referrals.
In short, this guide serves as a tool for program managers to not only begin to address GBV within
their programs, but also to plan for greater integration and coordination within country teams when
designing workplans and budgets. Ideally, this guide will catalyze dialogue, action, and resource
mobilization, building on PEPFAR programs and platforms for addressing GBV with national
governments, implementing partners, and other key stakeholders.
LIMITATIONS OF THE GUIDE
This guide represents a starting point for HIV programmers and planners who may have limited
exposure to or experience with GBV and integrated programs. As such, it does not address the two-
way integration of HIV services into existing GBV programs, although it should, at minimum, serve
as a basis for dialogue with GBV service providers. Nor does the guide provide comprehensive,
detailed technical information for implementing GBV services and programs; rather, it refers to
existing resources that have been developed by GBV experts. Finally, this guide does not address
GBV within the context of conflict, post-conflict, emergencies, disasters, and humanitarian
situations.
10

13. HOW TO USE THE GUIDE
The guide is divided into two parts that highlight key considerations, opportunities, and strategies
for addressing GBV within existing HIV programs (see Figure 2).
Figure 2. Steps for using the guide
1. The first part offers recommended practices for planning and implementing GBV programs.
These are cross-cutting principles and actions that should be applied to any and all programs and
services, regardless of technical area, sector, or approach (e.g., direct services, community
mobilization, policy advocacy).
a. Guiding principles for working with GBV survivors. This section outlines the guiding principles
that should be adopted before a GBV response is integrated into HIV programs and that
should be monitored while programs are being implemented. These principles are meant to
protect the rights, privacy, and dignity of those at risk for GBV as well as GBV survivors to
prevent further harm within service-based program settings.
b. Guidelines for GBV programming. This section provides an overview of the basic steps for
planning, launching, and evaluating efforts to address GBV, including consulting with
stakeholders, conducting a situational analysis, developing workplans, establishing a
monitoring and evaluation (M&E) plan, and budgeting.
2. The second part presents issues, opportunities, and actions for addressing GBV within each
PEPFAR technical area through the lens of PEPFAR priorities (e.g., integrating GBV within
HTC clinical services and addressing GBV in treatment adherence programs). Each technical
section can be used as a stand-alone guide; however, they are best used together in order to take
advantage of the full range of opportunities to address GBV and to achieve the goal of greater
11

14. linkages between HIV prevention, treatment, care, and support. The technical areas included in
this guide are as follows:
• Prevention
• HTC
• Prevention of mother-to-child transmission (PMTCT)
• Adult treatment
• Care and support
• OVC
Recommended Resources: Throughout the guide, recommended resources are identified to direct
users to detailed technical information for implementing the integration strategies. They include
practical tools for program planners and implementers (e.g., checklists for program managers;
sample client intake and consent forms; training curricula and resources; and questionnaires for
conducting situational analyses). To the extent possible, the resources selected were specifically
developed for use in low and middle income settings and have applicability across countries. The
resources included in this guide are illustrative; their selection does not constitute an exhaustive list
of available expertise. Full reference information for all of the recommended resources is listed at
the end of the guide.
METHODOLOGY
This guide is based on an extensive review of existing English language literature for mobilizing a
comprehensive response to GBV within the context of HIV. Keywords used in the search include
“gender based violence,” “gender and HIV/AIDS,” “women and AIDS,” “violence against
women,” and “sexual violence against women.” To the extent possible, articles and recommended
resources selected for inclusion in this guide were developed or can be adapted for low- and middle-
income settings. The literature reviewed includes original research, program evaluations, clinical and
professional guidelines, resource manuals, and training materials produced by technical experts and
normative agencies such as WHO and CDC. Also included are materials produced by civil society
advocates and implementers working to address GBV, gender equality, human rights, development,
HIV, and the health needs and rights of marginalized populations. The guide underwent multiple
reviews by GBV experts, U.S. Government headquarters and field staff and PEPFAR Technical
Working Groups.
12

15. GUIDING PRINCIPLES FOR
WORKING WITH SURVIVORS
OF GENDER-BASED
VIOLENCE
All programs seeking to address GBV must first and foremost protect the dignity, rights, and well-
being of those at risk for, and survivors of, GBV. The following section outlines four fundamental
principles for integrating a GBV response into existing programs and specific actions for putting
these principles into practice. These principles are as follows:
• Do no harm
• Privacy, confidentiality, and informed consent
• Meaningful engagement of people living with HIV (PLHIV), in particular women living with
HIV and GBV survivors
• Accountability and M&E.
13

16. Do No Harm
Service Provision
Adherence to ethical codes of conduct is particularly relevant when working with GBV survivors, namely:
• Autonomy. The right of GBV survivors to make decisions on their own behalf. All steps taken in providing
services are based on the informed consent of the survivor.
• Beneficence. The duty or obligation to act in the best interests of the survivor.
• Non-malfeasance. The duty or obligation to avoid harm to the survivor.
• Justice or fairness. Providing universal access to services without judgment or negative repercussions for the
client (WHO 2003).
Actions The principle of “do no harm” translates into awareness of the needs and wishes of the
client, displaying sensitivity and compassion, and maintaining objectivity (WHO 2003). This
should be reinforced through:
• Organizational policies to address violence and sexual harassment
• Codes of conduct
• Sensitization of staff on issues of power and control within the context of gender
inequality and in health service settings
• Ongoing training and support for communicating with GBV survivors, for example,
guidance on how to ask about violence and validate survivors’ experiences
• Hiring staff or trained volunteers from the same backgrounds as GBV survivors
• Safety planning for GBV survivors and their families.
Recommended A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health
Resources Facilities: Lessons and Tools from Sexual Violence Services in Africa: Tools and
resources to establish and strengthen GBV services within existing public health facilities,
improve linkages with other sectors, and engage local communities (Keesbury and
Thompson 2010)
Communication Skills in Working with Survivors of Gender-based Violence: Training
manual (Family Health International [FHI], Reproductive Health for Refugees Consortium
[RHRC], and International Rescue Committee [IRC] 2004)
Improving the Health Sector Response to Gender Based Violence: Includes a
management checklist and tools for developing key policies and protocols, improving
danger assessments, and providing safety plans (Bott, Guezmes, and Claramunt 2004)
14

17. Do No Harm
Program Design
Program planners and implementers must be fully aware of the local context in which programs and services are
delivered to avoid further harm to GBV survivors or putting individuals at increased risk of violence and to protect
the safety of everyone involved. Programs, services, and messages must be developed in partnership with those
they are meant to serve and reviewed by primary stakeholders to avoid reinforcing harmful social norms and
ensure cultural sensitivity.
Actions • Coordinate activities and messages to minimize duplication and gaps in response
• Commit to evaluation, openness to scrutiny, and external review
• Develop cultural and gender sensitivity and competence
• Stay updated on the evidence base regarding effective practices and the value of
participatory approaches
• Involve GBV survivors in decisions on accessibility, type and quality of services, and
communications materials (Inter-Agency Standing Committee [IASC] 2007).
Recommended A Manual for Integrating the Programmes and Services of HIV and Violence against
Resources Women: Stakeholder mapping tool (Ferdinand 2009)
A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health
Facilities: Lessons and Tools from Sexual Violence Services in Africa: Tools and
resources to establish and strengthen GBV services within existing public health facilities,
improve linkages with other sectors, and engage local communities (Keesbury and
Thompson 2010)
HIV & AIDS - Stigma and Violence Reduction Intervention Manual: Tools for
implementing community-owned processes in development programs (Duvvury, Prasad,
and Kishore 2006)
Improving the Health Sector Response to Gender Based Violence: Rapid situational
analysis tool; management checklist (Bott, Guezmes, and Claramunt 2004)
Virtual Knowledge Centre to End Violence against Women and Girls: Module on
programming essentials (U.N. Entity for Gender Equality and the Empowerment of
Women [UN Women] n.d.-a)
15

18. Do No Harm
Special Populations
Children and adolescents. Children and adolescents need age-specific services for post-rape care, reproductive
health, and HIV care and support that must include protocols and counseling that are developmentally appropriate.
Child and adolescent GBV survivors should be linked to child protective services where they exist.
Most-at-risk populations (MARPs). Sex workers, people who inject drugs, men who have sex with men
(MSM), and transgender people are among the most vulnerable to GBV and may face stigma, discrimination, and
violence perpetrated by the very personnel, such as health care workers and law enforcement officials, that are
charged with protecting their health and rights (Betron and Gonzalez-Figueroa 2009; Burns 2009; Sex Workers’
Rights Advocacy Network 2009). Stigma and discrimination against MARPs must be proactively addressed in HIV
programs so that these populations can access appropriate services.
Actions • Conduct ongoing training with all staff on the rights of MARPs and special needs of each
group
• “Do more than train”; challenge stakeholders on issues of stigma and discrimination
• Establish safe virtual and physical spaces for specific MARP groups to seek information and
referrals for care and support
• Address gender barriers in accessing post-exposure prophylaxis.
Recommended Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance
Resources (PEPFAR 2010)
Developing Services for Female Drug Users: Training module (Eurasian Harm Reduction
Network [EHRN] n.d.)
Gender-related Barriers to HIV Prevention Methods: A Review of Post-exposure
Prophylaxis Policies for Sexual Assault: Recommendations and key components for a
gender-sensitive post-exposure prophylaxis policy for sexual assault (Herstad 2009)
Identifying Violence Against Most-at-Risk Populations: A Focus on MSM and
Transgenders. Training Manual for Health Providers (Egremy, Betron, and Eckman
2009)
OVCSupport.net: Web portal (AIDSTAR-Two n.d.)
Protecting Children Affected by HIV Against Abuse, Exploitation, Violence and
Neglect (Long 2011)
Sex Work, Violence and HIV: A Guide for Programmes with Sex Workers (International
HIV/AIDS Alliance [IHAA] 2008)
Technical Guidance on Combination HIV Prevention: Men Who Have Sex with Men
(PEPFAR 2011)
Understanding Drug Related Stigma: Tools for Better Practice and Social Change
(Harm Reduction Coalition n.d.)
16

19. Privacy, Confidentiality, and Informed Consent
Privacy and confidentiality are essential for GBV survivors’ safety in any health care setting given that providers
can put the survivor’s safety at risk if they share sensitive information with partners, family members, or friends
without consent. A breach of confidentiality about pregnancy, rape, contraception, HIV status, or a history of
sexual abuse can put GBV survivors at risk of additional emotional, physical, or sexual violence. Moreover, those
who have already experienced violence need privacy in order to disclose those experiences to providers without
fear of retaliation from a perpetrator. To protect confidentiality and privacy, health programs need adequate
infrastructure and patient flow, as well as clear policies outlining when and where providers are allowed to
discuss sensitive information (Bott, Guezmes, and Claramunt 2004).
Actions • Establish clear policies and protocols for privacy and confidentiality
• Designate a private consultation space
• Provide ongoing training for staff on protecting survivors’ privacy and confidentiality
• Create opportunities to talk with survivors without partners, children, family, or friends
present
• Ensure privacy of medical information, including storage of information and policies
regarding sharing information
• Train providers on obtaining informed consent, including ensuring that GBV survivors are
informed of their options and their rights
• Ensure printed materials are accessible for both literate and illiterate clients, are
provided in local language(s), and that interpreters are available as needed.
Recommended A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health
Resource Facilities: Lessons and Tools from Sexual Violence Services in Africa: Tools and
resources to establish and strengthen GBV services within existing public health facilities,
improve linkages with other sectors, and engage local communities (Keesbury and
Thompson 2010)
Improving the Health Sector Response to Gender Based Violence: Management
checklist and tools for ensuring privacy and strengthening confidentiality (Bott, Guezmes,
and Claramunt 2004)
Meaningful Engagement of PLHIV, Particularly Women Living with HIV and GBV
Survivors
The critical role of PLHIV in all aspects of the response is well established, as is community ownership and
women’s participation (UNAIDS 1999). Involving PLHIV, specifically women living with HIV, in program planning,
implementation, and evaluation is paramount regardless of the type of GBV response being provided, be it direct
services, community mobilization, or policy advocacy. Participatory processes can facilitate access to and
acceptance and uptake of services and can help confront stigma and discrimination. It allows programs to build on
direct experience and tailor services to individuals and the contexts in which they are offered.
Actions • Provide training and ongoing support to empower individuals to participate in
organizational and community processes
• Create opportunities for participation, such as volunteering as counselors, advocates, and
health promoters
• Train and sensitize staff on greater involvement of PLHIV principle
• Plan for ongoing follow-up and communication with PLHIV.
Recommended Greater Involvement of People with AIDS (GIPA) Good Practice Guide (IHAA and the
Resource Global Network for People Living with HIV [GNP+] 2010)
17

20. Ensure Ongoing Quality Improvement and Assurance
As new programs and services are tested and launched, quality improvement and assurance mechanisms are
essential for ensuring that interventions are technically sound, implemented correctly, and meet the needs of the
people they are meant to serve, especially PLHIV, GBV survivors, communities, and other relevant stakeholders.
Quality assurance mechanisms for GBV services can include guidelines and protocols as well as data collection
tools also used for M&E. As with all GBV services, care should be taken to ensure the rights and safety of GBV
survivors and confidentiality when gathering client information and feedback used for quality assurance.
Actions • Develop mechanisms to monitor violence as a result of HIV-related interventions
• Roll-out of guidelines and policies (e.g., HIV testing and counseling, PMTCT) should
include plans for monitoring adverse outcomes
• Allocate sufficient resources for M&E activities
• Include mechanisms for client and provider feedback
• Train staff involved in collecting data on how to obtain informed consent from clients
• Ensure confidentiality and anonymity of data during collection, storage, and dissemination
• Ensure participation of all stakeholders in M&E planning and activities
• Communicate results, including to clients and providers.
Recommended A Manual for Integrating the Programmes and Services of HIV and Violence against
Resources Women: Guide for designing an exit survey for HIV and violence against women related
needs at testing and counseling sites (Ferdinand 2009)
A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health
Facilities: Lessons and Tools from Sexual Violence Services in Africa: Tools and
resources to establish and strengthen GBV services within existing public health facilities,
improve linkages with other sectors, and engage local communities (Keesbury and
Thompson 2010)
Improving the Health Sector Response to Gender Based Violence: Data collection
tools (provider knowledge, attitudes, and practice); clinic observation tools; client exit
questionnaire; protocol for collecting qualitative information; random record review
protocol; management checklist (Bott, Guezmes, and Claramunt 2004)
Researching Violence Against Women, A Practical Guide for Researchers and
Activists: Tools for collecting and analyzing data (Ellsberg and Heise 2005)
18

21. GUIDELINES FOR GENDER-
BASED VIOLENCE
PROGRAMMING
Programming guides on GBV almost universally recommend a comprehensive, rights-based, multi-
sectoral approach that simultaneously addresses survivors’ immediate and long-term needs and
rights, the role of communities in preventing and responding to violence, and the legal and policy
environment in which violence occurs. Further, ensuring a relevant, effective, and sustainable
response requires systematic planning to ensure local relevance and appropriateness, achieve
community commitment and support, and make the best use of existing resources and expertise.
The following steps are intended to assist program planners in achieving these objectives:
• Conduct a situational analysis
• Employ a rights-based, gender-sensitive approach
• Plan for and support community participation
• Pay special attention to the needs of young people
• Identify MARPs
• Develop a workplan
• Establish an M&E framework and plan
• Budget.
19

22. Conduct a Situational Analysis
A situational analysis is a fundamental step for understanding the extent to and context in which GBV takes place,
including its drivers, and the relationship between GBV and HIV infection and their impact on individuals, their
families, and communities. New programs and services must be developed with an understanding of existing
services and gaps across multiple sectors, including the health, legal, education, and social sectors.
Actions Macro level:
• Identify data collection mechanisms such as demographic health surveys and
administrative statistics maintained by police, hospitals, and judicial and social service
agencies
• Collect and analyze epidemiological data on the prevalence of GBV, HIV, and other
sexually transmitted infections (STIs)
• Review and assess national, provincial, and local plans, laws, policies, and budgetary
allocations related to the prevention of and response to GBV, including property and
inheritance rights and access to sexual and reproductive health services.
Sectoral level:
• Assess sectoral responses (e.g., health, education, justice, social) to GBV such as
inclusion in sectoral plans and the presence of coordinating mechanisms.
Community level:
• Identify customary laws, traditional practices, and norms and responses that may increase
vulnerability to HIV and GBV
• Map existing services and programs and the level of coordination between them.
Institutional level:
• Conduct readiness and capacity assessments for integrating a response to GBV within
existing programs.
Individual level:
• Assess risk perception for HIV infection and STIs, awareness of and sensitization to GBV;
attitudes regarding gender roles and norms; and the use of and need for relevant
services.
Recommended A Manual for Integrating the Programmes and Services of HIV and Violence against
Resources Women: Tools for conducting a situational analysis and evaluation of the legal framework
(Ferdinand 2009)
A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health
Facilities: Lessons and Tools from Sexual Violence Services in Africa: Tools and
resources to establish and strengthen GBV services within existing public health facilities,
improve linkages with other sectors, and engage local communities (Keesbury and
Thompson 2010)
Improving the Health Sector Response to Gender Based Violence: Rapid situational
analysis tool (Bott, Guezmes, and Claramunt 2004)
Preventing Intimate Partner and Sexual Violence Against Women: List of potential
sources of data and information by data category (WHO and London School of Hygiene
and Tropical Medicine 2010, 64)
Twubakane GBV/PMTCT Readiness Assessment: Questionnaires and focus group
discussion guides designed for introducing GBV services within health care settings
(IntraHealth International 2008)
20

23. Use a Rights-based and Gender-sensitive Approach
Both GBV and HIV have strong links to human rights because violations of human rights contribute to
vulnerabilities, and both can lead to further violations such as stigma, discrimination, and violence. Vulnerability to
HIV and GBV can be traced to social, political, educational, and economic inequalities.
A rights-based, gender-sensitive approach to programming supports the empowerment and agency of affected
populations, particularly women, girls, and MARPs, and aims to upend the structural drivers of HIV and GBV,
including all forms of discrimination.
Actions Principles of a rights-based approach to services:
• Participatory, nondiscriminatory, and a system for accountability
• Available to even the most marginalized groups, accessible (financially, geographically,
linguistically), acceptable, and of high quality
• Voluntary and noncoercive; premised on informed choice and informed decision-making
• Available with guarantees of privacy and confidentiality
• Evidence-based and developed in light of acquired experience about how to best address
the intersections between GBV and HIV (Women Won’t Wait 2010).
Principles of a gender-sensitive approach to programming:
• Work through community partnerships
• Support diversity and respect
• Foster accountability
• Promote respect for the rights of individuals and groups
• Empower women, girls, and communities
• Work with men and boys to transform harmful gender norms, attitudes, and behaviors
• Conduct gender analysis or gender assessments to identify the gender needs of women,
girls, men, boys, and MARPs (Inter-Agency Gender Working Group [IGWG] 2006).
Recommended A Manual for Integrating Gender into Reproductive Health and HIV Programs: Six-
Resources step process for enhancing gender-sensitive programming (Caro 2009)
An Essential Services Package for an Integrated Response to HIV and Violence
Against Women: Includes specific steps for providing a rights-based and gender-sensitive
approach within health, legal, humanitarian, and faith settings (Women Won’t Wait 2010)
Engaging Men and Boys in Changing Gender-based Inequity in Health: Evidence from
Program Interventions (WHO 2007a)
Gender and Sexual and Reproductive Health 101: Web course (Doggett, Krishna, and
Robles 2010)
IGWG Gender, Sexuality, and HIV Training Module (IGWG 2010)
International Guidelines on HIV/AIDS and Human Rights: Guidelines for states;
instructions for both policymakers and advocates, including how to ensure accountability
(UNAIDS 2006)
Virtual Knowledge Centre to End Violence against Women and Girls: Modules on
adopting human right-based approaches and ensuring gender responsiveness (UN
Women n.d.-a)
21

24. Ensure Community Participation in Program Planning, Implementation, and Evaluation
Plan for and support community participation throughout all phases of the program cycle including planning,
implementation, monitoring, evaluation, and program improvements.
Actions • Include key stakeholders in program planning, implementation, and evaluation, with
particular consideration of the following groups:
– Women and girls
– PLHIV, especially women living with HIV
– GBV survivors
– Youth, especially girls and young women and including married adolescents and young
adults
– Most at-risk and marginalized populations (e.g., people who inject drugs, sex workers,
sexual minorities)
– Men and boys
– GBV experts, women’s groups, and youth-led and -serving organizations
– Community leaders
– Service providers (public, private, and nongovernmental organizations)
– Law enforcement
– Educators
– Health care providers
– Policymakers
• Conduct stakeholder analyses and needs assessments regarding, for example, the
prevalence of GBV, availability of services, and knowledge of protective laws and policies
• Initiate and support community dialogues
• Establish and support program advisory committees or consultations, whether on an ad
hoc or formal basis.
Recommended A Manual for Integrating the Programmes and Services of HIV and Violence against
Resources Women: Stakeholder mapping tool (Ferdinand 2009)
Greater Involvement of People with AIDS (GIPA) Good Practice Guide (IHAA and
GNP+ 2010)
HIV & AIDS - Stigma and Violence Reduction Intervention Manual: Tools for
implementing community-owned processes in development programs (Duvvury, Prasad,
and Kishore 2006)
Implementing Stepping Stones: A Practical and Strategic Guide for Implementers,
Planners, and Policy Makers: Tools for engaging communities on gender and HIV
(Agency for Cooperation and Research in Development [ACORD] 2007)
Project H: Working with Young Men to Promote Health and Gender Equity (Instituto
Promundo 2002)
The SASA! Activist Kit for Preventing Violence Against Women and HIV:
Comprehensive set of tools for community-based action (Raising Voices 2009b)
22

25. Pay Attention to the Special Needs of Children and Adolescents
GBV can occur throughout the lifecycle, even starting before birth in some cases. Understanding the scope of
GBV as it pertains to children and adolescents, including the settings in which GBV can occur and ensuring age-
appropriate prevention and response strategies, is necessary to help break the cycle of violence in communities.
Prenatal: Sex-selective abortion; battering during pregnancy (emotional and physical effects on the woman;
effects on birth outcome); coerced pregnancy (e.g., pregnancy as a result of rape).
Infancy: Female infanticide; child abandonment; emotional and physical abuse; rape; differential access to food
and medical care for female infants.
Childhood: Early and forced marriage; genital cutting and mutilation; abuse by family members and strangers;
incest; rape; differential access to food and medical care; child prostitution; parental abandonment; and forced
labor and child trafficking.
Adolescence: Dating and courtship violence; physical violence; intergenerational and transactional sex; sexual
abuse in schools and workplaces; rape (incest, “date rape,” coercion); forced prostitution; sexual harassment; and
trafficking in persons.
Reproductive: Sexual abuse of women, girls, and sexual minorities; marital rape; dowry abuse and murders;
partner homicide; psychological abuse; physical abuse; sexual abuse in the workplace; sexual harassment; rape;
abuse of women with disabilities.
Old-age: Abuse of widows; elder abuse.
Source: Heise, Pitanquy, and Germain 1994
Actions • Situational analyses should include data on the prevalence and forms of GBV
disaggregated by sex, gender, age, marital status, and education level
• Review and assess legal and policy environments as they relate specifically to children and
young people (e.g., child protection policies; laws related to adolescent sexual and
reproductive health; and age of consent)
• Build capacity and strengthen referral systems to address child sexual abuse as it is one of
the most common forms of GBV experienced by children
• Raise awareness about the specific vulnerabilities of adolescent girls and young women to
GBV
• Promote child- and youth-friendly services
• Ensure access to sexual and reproductive health information and services for young
people
• Integrate GBV interventions within youth-specific services
• Involve youth in the program cycle
• Include married adolescents and young people, especially girls, as key stakeholders
• Engage girls and boys, in community mobilization strategies.
Recommended Gender Matters: A Manual on Addressing Gender-based Violence Affecting Young
Resources People (Council of Europe 2007)
Gender-based Violence: Care and Protection of Children in Emergencies, A Field
Guide (Save the Children 2004)
OVCSupport.net: Web portal (AIDSTAR-Two n.d.)
Protecting Children Affected by HIV Against Abuse, Exploitation, Violence, and
Neglect (Long 2011)
Report of the Independent Expert for the United Nations Study on Violence Against
Children: Addresses all forms of violence against children including GBV (U.N. Secretary
General 2006)
Women, Girls, Boys, and Men: Different Needs – Equal Opportunities: Gender
Handbook in Humanitarian Situations: Includes a series of questions on what to look
for or ask so that programs are designed and implemented with sensitivity to the
different needs of women, girls, boys, and men (IASC 2006)
23

26. Ensure Inclusion of MARPs
A review of available data found that GBV is an issue among MARPs (Spratt 2010). One study found that 68
percent of young MSM received threats from family members or partners and that MSM are 19 times more likely
to be HIV-positive. Likewise, a study of sex workers found that 49 percent experienced physical violence or
forced sex (Betron and Gonzalez-Figueroa 2009).
Government responses to addressing the HIV epidemic among MARPs have been disturbingly limited, and
programs for MARPs are significantly underfunded (Spratt 2010). Very few programs are integrating a GBV
response into programs with MARPs (MSM; transgender persons; male, female, and transgender sex workers; and
people who inject drugs) and their intimate partners. In many places, the behaviors are illegal, stigmatized, or
both, adding another layer of complexity to understanding the prevalence of GBV and providing appropriate
responses.
Actions • Situational analyses should include data on MARPs and involve MARPs in program design,
particularly to understand how sexual dynamics, normative expectations, and gender
scripts influence individual behavior and risk reduction strategies
• Train health care workers on gender norms and sexual identity and address provider
attitudes toward MARPs
• Identify and address gaps in services (e.g., policies barring female drug users from using
shelters; services for male and transgender sex workers and pregnant women who inject
drugs)
• Target partners and families of MARPs
• End impunity for violence perpetrated by police and national security agencies and
provide training and sensitization on the needs and rights of MARPs
• Ensure gender-sensitive eligibility for post-exposure prophylaxis for male victims of
sexual violence, incarcerated men, and transgender people
• Reduce stigma and discrimination of GBV survivors by police, judiciary, medical, and
social services personnel.
Direct services:
• Conduct ongoing training with all staff on the rights of MARPs and the special needs of
each group and how to best meet their needs without judgment or discrimination
• “Do more than train”; engage stakeholders on issues of stigma and discrimination
• Establish safe virtual and physical spaces for specific MARP groups to seek information
and referrals for care and support
• Set up convenient hours with few criteria for eligibility and use of services (low threshold
services).
Community mobilization:
• Increase awareness in the community, including among young people, that the use of
alcohol and other drugs does not cause GBV, and will therefore not be accepted as an
excuse for such behavior
• Refer to population-specific support (where they exist) such as drug treatment services,
mental health services, peer-based counseling services, and advocacy organizations
• Link up with other partners, such as local authorities, service providers, human rights
organizations, and welfare and social support organizations to help them respond to the
needs of MARPs; help them let MARPs know that certain services exist
• Roll-out intensive training of police officers in gender sensitivity, laws about rape and
intimate partner violence, the rights of women and children, investigation, and
prosecution of officers’ abuse of MARPs, including fact-based discussion around
economics and social inequality as driving factors for entry to sex work, drug use, and
high-risk behaviors.
24

27. Ensure Inclusion of MARPs (continued)
Actions Advocacy:
• Educate MARPs about the laws so they are aware of their rights and protections
• Conduct advocacy activities to ensure that MARPs have full access to human rights and
social services, as they are often excluded from them
• Increase the implementation of laws and policies by law enforcement and judiciary to
hold perpetrators of violence accountable
• Remove legal barriers that undermine access to HIV-related services such as laws that
criminalize consensual sex between men, carrying injection equipment, or voluntary sex
work
• Advocate for increased support and services from government and donors to be able to
strengthen and expand on existing services and programs.
Recommended Blueprint for the Provision of Comprehensive Care to Gay Men and Other Men Who
Resources Have Sex with Men in Latin America and the Caribbean (PAHO 2010)
Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance
(PEPFAR 2010)
Developing Services for Female Drug Users: Training module (EHRN n.d.)
Gender Identity, Violence, and HIV among MSM and TG: A Literature Review and a
Call for Screening: Screening tool (Betron and Gonzalez-Figueroa 2009)
Gender-related Barriers to HIV Prevention Methods: A Review of Post-exposure
Prophylaxis Policies for Sexual Assault: Recommendations and key components for a
gender-sensitive post-exposure prophylaxis policy for sexual assault (Herstad 2009)
Identifying Violence Against Most-at-Risk Populations: A Focus on MSM and
Transgenders. Training Manual for Health Providers (Egremy, Betron, and Eckman
2009)
IGWG Gender, Sexuality, and HIV Training Module (IGWG 2010)
Sex Work, Violence and HIV: A Guide for Programmes with Sex Workers (IHAA 2008)
Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention,
Treatment and Care for Injecting Drug Users (WHO 2009)
Technical Guidance on Combination HIV Prevention: Men Who Have Sex with Men
(PEPFAR 2011)
UNAIDS Action Framework: Universal Access for Men Who Have Sex with Men and
Transgender People (UNAIDS 2009)
Understanding Drug Related Stigma: Tools for Better Practice and Social Change
(Harm Reduction Coalition n.d.)
25

28. Develop a Workplan
Efforts to respond to and prevent GBV must be developed within the context of a comprehensive, multi-sectoral,
multilevel response, with interventions targeted at the individual, community, and policy levels. Because no single
program can address all of these needs, effective coordination is essential not only to avoid duplication of efforts
but also to ensure that individuals experiencing or at risk of GBV have access to services that are age-, sex- and
gender-appropriate and address their physical, psychological, emotional, and economic needs and well-being.
Actions Policy environment: Develop, strengthen, and enforce protective laws and policies
Public sector: Improve health, education, social welfare, and judicial and legal systems
Direct services: Provide high-quality, compassionate services for GBV survivors
Community mobilization: Work with communities to support PLHIV and GBV
survivors and identify and address harmful norms and HIV- and gender-related stigma and
discrimination that perpetuate GBV
Coordination: Coordinate within and across sectors.
Recommended A Manual for Integrating Gender into Reproductive Health and HIV Programs: Six-
Resources step process for enhancing gender-sensitive programming (Caro 2009)
A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health
Facilities: Lessons and Tools from Sexual Violence Services in Africa: Tools and
resources to establish and strengthen GBV services within existing public health facilities,
improve linkages with other sectors, and engage local communities (Keesbury and
Thompson 2010)
Addressing Gender-based Violence through USAID’s Health Programs: A Guide for
Health Sector Program Officers: Planning tool for addressing GBV within different
types of health programs including community mobilization, communications for behavior
change, and health policy (IGWG of USAID 2008)
An Essential Services Package for an Integrated Response to HIV and Violence
Against Women: Outlines key actions for mobilizing an integrated response to GBV and
HIV within health care, school, humanitarian, faith, and legal settings (Women Won’t
Wait 2010)
Improving the Health Sector Response to Gender Based Violence: Step-by-step
guidance on addressing GBV within the health sector (Bott, Guezmes, and Claramunt
2004)
Preventing Intimate Partner and Sexual Violence Against Women: Planning guide
geared toward policymakers, program planners, and funding bodies (WHO and London
School of Hygiene and Tropical Medicine 2010)
Strategic Framework for the Prevention of and Response to Gender-based Violence in
Eastern, Southern and Central Africa: Program building blocks and sample activities
(USAID/Eastern and Central Africa and U.N. Children’s Fund [UNICEF]/East and
Southern Africa Regional Offices n.d.)
Virtual Knowledge Centre to End Violence against Women and Girls: Module on
programming essentials (UN Women n.d.-a)
26

29. Develop an M&E Plan
Although there has been an increase in services and programs designed to address GBV, there is a continuous
and ongoing need for evidence-based knowledge regarding effective GBV prevention, integrated GBV and HIV
programs, and scale up of services. Rigorous M&E plans are critical for tracking the prevalence of GBV; assessing
the effectiveness of related services and programs, including outcomes for GBV survivors; and determining the
impact of any given intervention. M&E processes and mechanisms create opportunities for community
engagement, for example, through focus groups to determine baseline attitudes and changes over time, or client
feedback surveys.
Actions • Ensure data collection adheres to ethical and safety guidelines, including to ensure
confidentiality of client data
• Provide cross-sector training on complete and accurate data collection, including incident
reports which are essential for facilitating GBV survivors’ access to justice
• Coordinate data collection, record keeping and tracking between service providers and
across sectors
• Employ participatory methods, especially to analyze and reflect on data and findings in
order to translate them into program improvements
• Share evidence and findings with:
– Internal audiences (e.g., staff, GBV survivors)
– Partners in the response to GBV (e.g., advocacy organizations, and local governmental,
nongovernmental, and private sector partners)
– Communities
– Policymakers
– Media.
Recommended Evaluating Services for Survivors of Domestic Violence and Sexual Assault (Riger et al.
Resources 2002)
Outcome Evaluation Strategies for Domestic Violence Service Programs Receiving
FVPSA Funding: A Practical Guide (Lyon and Sullivan 2007)
Researching Violence Against Women, A Practical Guide for Researchers and Activists
(Ellsberg and Heise 2005)
The Gender-based Violence Information Management System: Online tools for incident
reporting, tracking, and analysis and data sharing protocols designed to facilitate
coordination among agencies (U.N. Population Fund [UNFPA], IRC, and U.N. Refugee
Agency [UNHCR] n.d.)
Violence against Women and Girls: A Compendium of Monitoring and Evaluation
Indicators (Bloom 2008)
Develop a Budget
Dedicated resources are essential for operationalizing PEPFAR’s commitment to addressing and reducing GBV.
Analyses of budget allocations versus expenditures are also important for measuring and evaluating program
impact, costs, and benefits.
Actions • Identify and prioritize the problem (e.g., the impact of GBV on accessing services; gaps in
stakeholder knowledge, attitudes, and practices)
• Identify associated costs and develop a budget for planned activities (e.g., additional
training; information, education and communication materials; communications
campaigns; and advocacy)
• Monitor the extent to which resources are used for intended purposes and reach
intended beneficiaries
• Evaluate the impact of the resources spent.
27

30. 28

31. PREVENTION
There is growing consensus that HIV prevention programs must not only address the biomedical
and behavioral factors involved in transmission, but also the underlying social and structural drivers
that increase vulnerability. Social, political, and economic inequities fuel women’s and girls’
vulnerability to HIV and GBV. Likewise, stigma and discrimination, including against MARPs such
as MSM, sex workers, transgender people, and people who inject drugs, make it impossible to
prevent or treat HIV through biomedical and behavioral approaches alone. While the evidence base
for both HIV structural prevention and GBV prevention are limited, strategies to empower women
and girls, engage men and boys, and challenge harmful social norms show promise for addressing
the underlying drivers of HIV and GBV, simultaneously reducing the risk and vulnerabilities to
both.
Addressing GBV within prevention programs can have a direct impact on reaching
PEPFAR prevention targets, specifically:
• Working with countries to track and reassess their HIV epidemic in order to fashion an
evidence-based prevention response based on best available and most recent data
• Emphasizing HIV prevention strategies that have been proven effective at achieving intended
outcomes and targeting interventions to MARPs with high incidence rates
• Increasing emphasis on supporting and evaluating innovative and promising HIV prevention
methods
• Expanding integration of HIV prevention programs with family planning and reproductive
health services, so that women living with HIV can access necessary care, and so that all women
know how to protect themselves from HIV infection
• Expanding PEPFAR’s commitment to cross-cutting integration of gender equality in its
programs and policies, with a focus on addressing and reducing GBV.
29

32. Addressing GBV within Prevention Programs for the General Population
Combination HIV prevention strategies can simultaneously contribute to GBV prevention, dismantling the
structural drivers of both.
Actions to Address Gender-based Violence Recommended Resources
Community-based actions: Gender-related Barriers to HIV
• Include GBV in HIV prevention curricula and peer education Prevention Methods: A Review of
programs and provide information about and access to GBV Post-exposure Prophylaxis Policies
support services for Sexual Assault: Recommendations
for increasing access (Herstad 2009)
• Mobilize communities on GBV and HIV, specifically, the links
between the two and how harmful gender norms, beliefs, and Handbook for Legislation on Violence
practices contribute to both against Women (U.N. Division for the
Advancement of Women [UNDAW]
• Support life skills education for boys and girls through both in- and 2009)
out-of-school programs.
Implementing Stepping Stones: A
Health facility-based actions: Practical and Strategic Guide for
• Raise awareness among all cadres of health care workers about Implementers, Planners, and Policy
GBV as a risk factor for HIV infection Makers: Tools for promoting
community awareness and life-skills
• Train and support health care providers to screen for violence
education (ACORD 2007)
where counseling and referral services exist
Preventing Intimate Partner and Sexual
• Link GBV and HIV prevention and awareness programs with
Violence Against Women: Evidence-
voluntary medical adult male circumcision services
based promising practices in violence
• Support GBV survivors in negotiating risk reduction behaviors such prevention (WHO and London School
as condom use of Hygiene and Tropical Medicine 2010)
• Ensure timely access to post-exposure prophylaxis Project H: Working with Young Men to
• Ensure access to female condoms. Promote Health and Gender Equity
(Instituto Promundo 2002)
Structural actions:
The SASA! Activist Kit for Preventing
• Ensure protective laws and policies are in place and enforced to Violence Against Women and HIV:
prevent GBV Comprehensive set of tools for
• Challenge harmful gender norms, roles, and behaviors, and reduce community-based action (Raising Voices
acceptance of GBV 2009b)
• Support girls’ and women’s access to education because increased Training Professionals in the Primary
educational attainment has been linked to increased protection Prevention of Sexual and Intimate
from HIV infection and violence Partner Violence: A Planning Guide
• Promote women’s and girls’ economic security through livelihood (Fisher, Lang, and Wheaton 2010)
programs and ensure their property and inheritance rights
• Support research on female-initiated methods of HIV prevention
• Ensure policies are in place that promote linkages between GBV
and HIV, and support programs that address harmful gender
norms, beliefs, and practices that contribute to GBV and HIV.
30

33. Addressing GBV within Prevention Programs with MARPs
Actions to Address Gender-based Violence Recommended Resources
Community-based actions: Blueprint for the Provision of Comprehensive Care
• Ensure that information on GBV is addressed within to Gay Men and Other Men Who Have Sex with
HIV programs consistent with the context of the Men in Latin America and the Caribbean (PAHO
country’s HIV epidemic, including the most 2010)
vulnerable populations. Comprehensive HIV Prevention for People Who
Inject Drugs, Revised Guidance (PEPFAR 2010)
Health facility-based actions:
Developing Services for Female Drug Users: Training
• Establish strong referral and coordination module (EHRN n.d.)
mechanisms between HIV and GBV services as well
Gender Identity, Violence, and HIV among MSM and
as services designed specifically for MARPs (e.g.,
TG: A Literature Review and a Call for Screening:
methadone replacement therapy, outreach to sex
Screening tool (Betron and Gonzalez-Figueroa 2009)
workers)
Identifying Violence Against Most-at-Risk
• Address bias and discrimination among provider Populations: A Focus on MSM and Transgenders.
attitudes toward MARPs Training Manual for Health Providers (Egremy,
• Train health care workers and counselors on high- Betron, and Eckman 2009)
risk populations’ increased vulnerabilities to violence IGWG Gender, Sexuality, and HIV Training Module
• Address the impact of GBV on negotiating risk (IGWG 2010)
reduction strategies Sex Work, Violence and HIV: A Guide for
• Ensure access to male and female condoms to all Programmes with Sex Workers (IHAA 2008)
populations Technical Guidance on Combination HIV Prevention:
• Create linkages with substance abuse prevention Men Who Have Sex with Men (PEPFAR 2011)
services and programs that are friendly towards Technical Guide for Countries to Set Targets for
MARPs and have staff trained in GBV screening. Universal Access to HIV Prevention, Treatment
and Care for Injecting Drug Users (WHO 2009)
Structural actions: UNAIDS Action Framework: Universal Access for
• Ensure that information on GBV is addressed within Men Who Have Sex with Men and Transgender
HIV programs consistent with the context of the People (UNAIDS 2009)
country’s HIV epidemic, including the most Understanding Drug Related Stigma: Tools for Better
vulnerable populations. Practice and Social Change (Harm Reduction
Coalition n.d.)
31

34. Addressing GBV within Prevention Programs for Youth
HIV prevention programs for youth are an ideal vehicle for integrating primary prevention programs for GBV as
there is consensus that such efforts should focus on younger age groups.
Actions to Address Gender-based Recommended Resources
Violence
Community-based actions: Adolescents: Missing from Programs for the World’s
• Train and sensitize child- and youth-serving Orphans and Vulnerable Children: Overview of needs of
program staff and volunteers on GBV and the vulnerable adolescents with examples of programs that work
particular risk factors that children and young (Osborn 2007)
people face, for example, sexual violence Elimination of All Forms of Discrimination and Violence
including forced sex and coercion against the Girl Child, Report of the Expert Group
• Ensure that services and programs are tailored Meeting: Includes overview of the issues and
to the distinct needs of girls, boys, young recommendations for policy change, programming, and
women, and young men, acknowledging that nongovernmental organizations and civil society (UNDAW
programming is not necessarily the same for 2006)
each group Gender Matters: A Manual on Addressing Gender-based
Violence Affecting Young People (Council of Europe
• Establish linkages between prevention
2007)
programs and age-appropriate services for
young GBV survivors Gender-related Barriers to HIV Prevention Methods: A
Review of Post-exposure Prophylaxis Policies for Sexual
• Include information on GBV in school-based
Assault: Recommendations and key components for a
programs to prevent HIV
gender-sensitive post-exposure prophylaxis policy for sexual
• Include HIV and GBV prevention information assault (Herstad 2009)
in comprehensive sexuality education for Preventing Intimate Partner and Sexual Violence Against
young people. Women: Includes age-specific promising practices for the
Health facility-based actions: primary prevention of violence (WHO and London School
of Hygiene and Tropical Medicine 2010)
• Ensure access to youth-friendly sexual and
Project H: Working with Young Men to Promote Health
reproductive health services that include GBV
and Gender Equity (Instituto Promundo 2002)
screening
Women, Girls, Boys, and Men: Different Needs – Equal
• Ensure gender-sensitive access to post-
Opportunities: Gender Handbook in Humanitarian
exposure prophylaxis for young people.
Situations: Includes a series of questions on what to look
Structural actions: for or ask so that programs are designed and implemented
• Support efforts to prevent all forms of violence with sensitivity to the different needs of women, girls, boys,
and abuse, especially child maltreatment and and men (IASC 2006)
child sexual abuse.
32

35. HIV TESTING AND
COUNSELING
GBV is a significant barrier to women’s use of HTC services, in turn hampering treatment scale-up
and prevention efforts (WHO 2006). Violence and fear of violence are often cited as barriers to HIV
testing and disclosing a positive test result (Hale and Vazquez 2011). In addition to physical
violence, women cite fear of abandonment, loss of economic support, rejection, and accusations of
infidelity as reasons for not seeking out HTC services or returning for test results. Experience with
violence and women’s low status within the family can negatively influence knowledge of where and
how to get tested; the level of autonomy and decision making individual family members have about
accessing health care; and access to resources, such as money for transportation, that impede
utilization of services (Ali 2007).
A 2006 WHO expert meeting identified four thematic areas for addressing GBV within HTC:
• A barrier to accessing services
• Safe disclosure of test results
• Ability to negotiate risk reduction behaviors
• Access to post-test support and care (WHO 2006).
Addressing GBV within HTC programs can have a direct impact on advancing
PEPFAR’s HTC strategies and reaching HTC targets, specifically:
• Addressing GBV within testing and counseling programs can improve uptake of services,
increasing the number of individuals who know their HIV status and 1) seek treatment, and 2)
have the information, tools, and support to prevent further infection.
• Expanding integration of HIV prevention, care and support, and treatment services with family
planning and reproductive health services so that women living with HIV can access necessary
care, and so that all women know how to protect themselves from HIV infection.
• Expanding PEPFAR’s commitment to cross-cutting integration of gender equality in its
programs and policies, with a focus on addressing and reducing GBV.
33

36. Addressing GBV within Strategic Scale-up of Provider-initiated HTC and HTC in
Community and Clinical Settings
Actions to Address Gender-based Violence Recommended Resources
Readiness: A Manual for Integrating
• Assess and identify if and how GBV influences women’s and men’s access to the Programmes and
HTC services Services of HIV and
Violence against Women:
• Assess community and policy environment to determine readiness to respond Recommendations for
to GBV in HTC programs integrating GBV services
• Establish linkages with police and law enforcement agencies. within voluntary counseling
Training: and testing programs
(Ferdinand 2009)
• Ensure adequate training in GBV screening and referral for all HTC providers
A Step-by-Step Guide to
• Provide additional training as needed for issues on links between GBV and Strengthening Sexual
HTC. Violence Services in Public
HTC services: Health Facilities: Lessons
• Ensure services are financially, geographically, and linguistically accessible to and Tools from Sexual
women and MARPs Violence Services in Africa:
Tools and resources to
• Raise awareness about GBV within “male-friendly” services (i.e., establish and strengthen
mobile/outreach, evening/weekend hours) GBV services within existing
• Utilize a family-centered approach that supports HTC for couples/partners and public health facilities,
children improve linkages with other
• Provide adequate and appropriate space for HTC services that allows for safety sectors, and engage local
and privacy communities (Keesbury and
• Ensure the “4 Cs” are adhered to: consent, confidentiality, counseling, and Thompson 2010)
correct test results Guidance on Couples HIV
Testing and Counseling
• Ensure that HTC services are not implementing mandatory testing or unlawful
(WHO Forthcoming)
disclosure
Guidance on Provider-
• Consider integrating screening and counseling for GBV as part of HTC services
Initiated HIV Testing and
where training and support are available; ensure counselors are equipped to
Counselling in Health
deal with GBV if suspected
Facilities: Information on
• Ensure provision of quality services (see section: Addressing GBV in HTC strategic scale-up of
Quality Assurance Approaches). provider-initiated testing
Ensuring safe disclosure: and counseling, including
minimum information for
• Train and support HTC providers to identify women who fear violence as a
obtaining informed consent
result of testing or disclosure and counsel them on how to address these fears
(WHO 2007b)
• Offer alternative models for disclosure including counselor-assisted disclosure
Guidelines for Medico-legal
• Provide couples/partner HTC to relieve burden on women for disclosing to Care for Victims of Sexual
male partners. Violence (WHO 2003)
Linkages and referrals: Improving the Health Sector
• Establish referral networks and coordination mechanisms within the Response to Gender
community and for GBV services Based Violence: Checklist
for conducting a situational
• Link clients proactively with GBV services as needed analysis and step-by-step
• Refer women and marginalized populations to peer groups to provide ongoing guidance for planning and
psychosocial support implementing GBV services
• Build support systems for GBV survivors where services do not exist (Bott, Guezmes, and
• Increase access to HTC by integrating HTC within GBV services. Claramunt 2004)
34

37. Addressing GBV within Strategic Scale-up of Provider-initiated HTC and HTC in
Community and Clinical Settings (continued)
Actions to Address Gender-based Violence Recommended Resources
Risk-reduction: Opening Up the HIV/AIDS
• Address violence as a barrier to negotiating risk reduction strategies and Epidemic: Guidance on
support survivors in developing strategies to protect themselves when Encouraging Beneficial
negotiating safer sexual relationships. Disclosure, Ethical Partner
Counselling & Appropriate
Use of HIV Case-reporting
(UNAIDS 2000)
Training Professionals in the
Primary Prevention of
Sexual and Intimate Partner
Violence: A Planning Guide
(Fisher, Lang, and Wheaton
2010)
Integrating GBV within Couples HIV Testing and Counseling (CHTC)
Actions to Address Gender-based Violence Recommended Resources
Increase availability of CHTC services: AIDS Information Centre
• Train providers to deliver CHTC in all HTC settings Uganda: Model program for
addressing GBV within the
• Educate clients and patients about the benefits of CHTC services, including context of couples counseling
GBV prevention. (AIDS Information Centre
Ensure quality CHTC service provision: Uganda n.d.)
• Ensure that neither member of the couple (or polygamous family) has been Couples HIV Counseling and
coerced to attend CHTC; train HTC providers to identify signs that either Testing Intervention and
partner has been coerced to attend CHTC or potential violence within the Training Curriculum (CDC
couple; these partners should be met with individually before proceeding 2007)
with CHTC; for couples where coercion or violence may be present, HTC * Important note: this resource is
providers may wish to recommend individual HTC or delay CHTC to a later currently under revision
time Guidance on Couples HIV
• Offer the entire HTC service together, including learning their test results Testing and Counseling
together if couples presenting for CHTC have discussed this decision jointly; (WHO Forthcoming)
separating couples could suggest secrecy or distrust, and may put HTC * See additional resources
providers in a compromising position if they learn something about one listed previously for HTC
partner that the client is not willing to share with the other
• Confirm that both partners are ready to receive and to disclose their results
together before the HTC provider reveals test results to the couple
• Offer both partners the opportunity to return to the HTC site (or refer to
appropriate site) for additional counseling and support, either as individuals
or as a couple
• Provide appropriate linkages and support for serodiscordant couples
• Provide additional follow-up to women in serodiscordant couples with
special attention to HIV-positive women who are at increased risk for
violence due to their HIV status.
35